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psnet.ahrq.gov/issue/connected-care-reducing-errors-through-automated-vital-signs-data-upload
September 01, 2018 - Study
Connected care: reducing errors through automated vital signs data upload.
Citation Text:
Smith LB, Banner L, Lozano D, et al. Connected care: reducing errors through automated vital signs data upload. Comput Inform Nurs. 2009;27(5):318-23. doi:10.1097/NCN.0b013e3181b21d65.
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psnet.ahrq.gov/issue/five-ways-you-can-reduce-inappropriate-prescribing-elderly-systematic-review
September 23, 2020 - Review
Five ways you can reduce inappropriate prescribing in the elderly: a systematic review.
Citation Text:
Garcia RM. Five ways you can reduce inappropriate prescribing in the elderly: a systematic review. J Fam Pract. 2006;55(4):305-12.
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psnet.ahrq.gov/issue/why-worry-worry-risk-perceptions-and-willingness-act-reduce-medical-errors
September 10, 2009 - Study
Why worry? Worry, risk perceptions, and willingness to act to reduce medical errors.
Citation Text:
Peters E, Slovic P, Hibbard JH, et al. Why worry? Worry, risk perceptions, and willingness to act to reduce medical errors. Health Psychology. 2006;25(2). doi:10.1037/0278-6133.25.…
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psnet.ahrq.gov/issue/bone-break-hot-debrief-tool-reduce-second-victim-syndrome-nurses
August 02, 2015 - Study
BONE break: a hot debrief tool to reduce second victim syndrome for nurses.
Citation Text:
Hess A, Flicek T, Watral AT, et al. BONE break: a hot debrief tool to reduce second victim syndrome for nurses. Jt Comm J Qual Patient Saf. 2024;50(9):673-677. doi:10.1016/j.jcjq.2024.05.005.…
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psnet.ahrq.gov/issue/making-surgical-wards-safer-patients-diabetes-reducing-hypoglycaemia-and-insulin-errors
February 18, 2019 - Commentary
Making surgical wards safer for patients with diabetes: reducing hypoglycaemia and insulin errors.
Citation Text:
Singh A, Adams A, Dudley B, et al. Making surgical wards safer for patients with diabetes: reducing hypoglycaemia and insulin errors. BMJ Open Qual. 2018;7(3):e000…
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psnet.ahrq.gov/issue/assessment-implementation-national-patient-safety-alert-reduce-wrong-site-surgery
March 28, 2011 - Study
Assessment of the implementation of a national patient safety alert to reduce wrong site surgery.
Citation Text:
Rhodes P, Giles SJ, Cook GA, et al. Assessment of the implementation of a national patient safety alert to reduce wrong site surgery. Qual Saf Health Care. 2008;17(6):…
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psnet.ahrq.gov/web-mm/overdose-gabapentin-and-oxycodone-patient-end-stage-renal-disease-case-appropriate
October 31, 2023 - SPOTLIGHT CASE
Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case for Appropriate Interruptive Drug-Disease Alerts.
Citation Text:
Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with End-Stage Renal Disease: A Case…
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psnet.ahrq.gov/node/843234/psn-pdf
January 01, 2013 - Overdose of Gabapentin and Oxycodone in a Patient with
End-Stage Renal Disease: A Case for Appropriate
Interruptive Drug-Disease Alerts.
February 1, 2023
Keenan CR, MacDonald S, Takeshita A, et al. Overdose of Gabapentin and Oxycodone in a Patient with
End-Stage Renal Disease: A Case for Appropriate Interruptive D…
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psnet.ahrq.gov/node/74099/psn-pdf
January 01, 2022 - Hemodialysis bleeding events and deaths: an 18-year
retrospective analysis of patient safety and root cause
analysis reports in the Veterans Health Administration.
November 24, 2021
Walton E, Charles M, Morrish W, et al. Hemodialysis bleeding events and deaths: an 18-year retrospective
analysis of patient safety a…
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psnet.ahrq.gov/node/867596/psn-pdf
January 22, 2025 - Creation of root cause analysis and action (RCA2)
standard work by a multidisciplinary team to prevent
harm, reduce bias, and improve safety culture.
January 22, 2025
Musheno D, Harnish M, Roberts J, et al. Creation of root cause analysis and action (RCA2) standard work
by a multidisciplinary team to prevent harm,…
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psnet.ahrq.gov/node/867636/psn-pdf
February 26, 2025 - Early experience of peer advocate program: using quality
improvement to optimize behavioral and communication
disconnect in the operating room.
February 26, 2025
Eckhouse SR, Huston M, Smith ER, et al. Early experience of peer advocate program: using quality
improvement to optimize behavioral and communication dis…
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psnet.ahrq.gov/node/839822/psn-pdf
November 09, 2022 - Understanding factors that could influence patient
acceptability of the use of the PINCER intervention in
primary care: a qualitative exploration using the
Theoretical Framework of Acceptability.
November 9, 2022
Laing L, Salema N-E, Jeffries M, et al. Understanding factors that could influence patient acceptabili…
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psnet.ahrq.gov/node/72669/psn-pdf
January 27, 2021 - Nosocomial transmission and outbreaks of coronavirus
disease 2019: the need to protect both patients and
healthcare workers.
January 27, 2021
Abbas M, Robalo Nunes T, Martischang R, et al. Nosocomial transmission and outbreaks of coronavirus
disease 2019: the need to protect both patients and healthcare workers. A…
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psnet.ahrq.gov/node/37706/psn-pdf
December 23, 2016 - Preventing pediatric medication errors.
December 23, 2016
Preventing pediatric medication errors. Sentinel event alert. 2008;39:1-4.
https://psnet.ahrq.gov/issue/preventing-pediatric-medication-errors
The Joint Commission issues sentinel event alerts one to two times yearly to highlight areas of high risk
and to p…
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psnet.ahrq.gov/node/73608/psn-pdf
January 01, 2022 - Pharmacist-led intervention on the reduction of
inappropriate medication use in patients with heart
failure: a systematic review of randomized trials and non-
randomized intervention studies.
August 18, 2021
Hernández-Prats C, López-Pintor E, Lumbreras B. Pharmacist-led intervention on the reduction of
inappropri…
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psnet.ahrq.gov/node/60550/psn-pdf
June 03, 2020 - Clinical efficacy of combined surgical patient safety
system and the World Health Organization's checklists in
surgery: a nonrandomized clinical trial.
June 3, 2020
Storesund A, Haugen AS, Flaatten H, et al. Clinical Efficacy of Combined Surgical Patient Safety System
and the World Health Organization’s Checklists…
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psnet.ahrq.gov/node/37498/psn-pdf
April 30, 2014 - Evaluation of a preoperative checklist and team briefing
among surgeons, nurses, and anesthesiologists to
reduce failures in communication.
April 30, 2014
Lingard LA. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and
Anesthesiologists to Reduce Failures in Communication. Archives…
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psnet.ahrq.gov/node/38243/psn-pdf
November 26, 2008 - Impact of preoperative briefings on operating room
delays.
November 26, 2008
Nundy S, Mukherjee A, Sexton B, et al. Impact of preoperative briefings on operating room delays: a
preliminary report. Arch Surg. 2008;143(11):1068-72. doi:10.1001/archsurg.143.11.1068.
https://psnet.ahrq.gov/issue/impact-preoperative-br…
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psnet.ahrq.gov/node/837804/psn-pdf
August 10, 2022 - Nurses' harm prevention practices during admission of an
older person to the hospital: a multi-method qualitative
study.
August 10, 2022
Redley B, Douglas T, Hoon L, et al. Nurses' harm prevention practices during admission of an older person
to the hospital: a multi?method qualitative study. J Adv Nurs. 2022;78(1…
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psnet.ahrq.gov/node/46325/psn-pdf
November 30, 2018 - Physician Burnout.
November 30, 2018
Rockville, MD: Agency for Healthcare Research and Quality; July 2017. AHRQ Publication No. 17-M018-1-
EF.
https://psnet.ahrq.gov/issue/physician-burnout
Clinician burnout can affect patient safety. This report highlights AHRQ-supported research to examine
burnout in health car…